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Sphincter of Oddi though mostly heard about in 'anatomy textbooks' is making its way into surgical practice due to various disease states affecting it and its dysfunction seems to be an important condition to be observed while treating patients with abdominal pain. In this review, we have attempted to discuss all the relevant conditions affecting it, particularly the dysfunction with a detailed literature review.

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Invasion of the Ascaris worm into the biliary system leads to a wide variety of clinical syndromes. Most of the descriptions of the disease have originated from the developing world, where due to the environmental factors there is a high level of parasitism. An increased incidence of biliary ascariasis borne out of population migration and increased facilities for diagnosis has led to a renewal of interest in this disease in the developed world. Significant morbidity and mortality is associated with the concomitant complications, and early diagnosis and management is of utmost importance. Common disease presentations include biliary colic, obstructive jaundice, acalculous cholecystitis, choledocholithiasis, pancreatitis, and cholangitis. Although with a potential for serious mortality, pancreatitis, and cholangiocarcinoma constitute relatively less common threats. Recent advances in endoscopy have shifted the attention of this disease from the surgeon to the gastroenterologist and a consensus of opinion is arising for early intervention. We present here a patient with biliary ascariasis managed endoscopically and review the epidemiology, prevalence, clinical presentation, diagnosis, and management of this disease.

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The mechanisms controlling the sphincter of Oddi (SO) have received considerable attention over the past two decades. Progress towards their elucidation has been slow, perhaps because of the sphincter's relative inaccessibility and the different responses of the human "resistor" as compared to the "pumper" observed in several animal models. The list of agents affecting the sphincter grows alarmingly. In this review, divided into two parts, substances have been classified as neurotransmitters, hormones, local factors and pharmacological agents. The first part considers the roles of neurotransmitters. These include (a) vasoactive intestinal polypeptide (VIP) and nitric oxide (NO). Both cause relaxation. A recent model of their complex interrelationships in smooth muscle is described. (b) Substance P (SP) and enkephalins. These produce contractions. The former can act directly. An indirect effect via cholinergic neurones may be the result of SP release from vagal afferents. (c) Catecholamines, which cause contraction or relaxation via activation of α- or β-adrenoreceptors, respectively. In the second part attention is focussed on cholecystokinin (CCK) which normally relaxes the SO via neuronal mechanisms. A CCK-sensitive pathway from sensory duodenal neurones to SO ganglia has been described. Reactive oxygen species are among the local factors discussed. Their description as being "the good, the bad and the ugly" seems merited. Pharmacological agents include NO donors, octreotide and botulinum toxin (BTX). Octreotide induces tachyoddia and may impair biliary flow. BTX has exciting potential in the diagnosis of SO abnormalities and as a therapeutic alternative to sphincterotomy. In both parts of the review current concepts of different aspects of smooth muscle control are presented. In several instances data regarding the SO is lacking. We discuss (a) the role of interstitial cell of Cajal in the control of slow waves, (b) different pathways contributing to tonic and phasic contractions, (c) the 4 levels of neural control, (d) interrelationships of immune and nervous systems, and (e) links between emotional states and gut functions.

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Gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition, worldwide. The pathogenesis of acute pancreatitis has not been fully understood. Laboratory and radiological investigations are critical for diagnosis as well prognosis prediction. Scoring systems based on radiological findings and serologic inflammatory markers have been proposed as better predictors of disease severity. Early endoscopic retrograde cholangiopancreatography (ERCP) is beneficial in a group of patients with gallstone pancreatitis. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for acute biliary pancreatitis. The timing of cholecystectomy, following ERCP, for biliary pancreatitis can vary markedly depending on the severity of pancreatitis

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Symptomatic gallstones are easy to treat, unfortunately however asymptomatic gallstones are as easy to treat. This creates a problem for health care planners in the form of the financial implications involved, since asymptomatic gallstones are even more common than gallstones associated with symptoms and require no surgical intervention, while the funds diverted towards dealing with them drains the health care establishment of much needed funds in an era of costly health care. In this review we attempt to clarify the fact that asymptomatic gallstones need no intervention in most cases, thereby saving the patient unnecessary surgery and the health care establishment costs, both in the financial form and in manpower.

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Portal hypertension is a commonly encountered clinical condition with multiple causes and several squeal. Ultrasound is an accurate non-invasive means of assessing its aetiology, severity and complications. I will review the role of ultrasonography in portal hypertension. The ultrasonic features that help identify its aetiology will be discussed as will the criteria that allow an assessment of disease severity and its complications.

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Background: Surgery in patients with schistosomal liver disease is usually associated with high risks of morbidity and mortality. Bilateral paravertebral block (BPVB) has been advocated as a useful technique for ventral abdominal hernias' repairs. Aim of the study: To compare the efficacy of BPVB with general anesthesia (GA) for anterior abdominal wall hernias in advanced schistosomal liver disease patients. Patients and Methods: Sixty patients were randomly allocated into two groups to receive either GA or BPVB. Variables were hospital stay, hemodynamic stability, postoperative nausea and vomiting (PONY), postoperative pain measured on a visual analogue scale (VAS) with assessment of the hepatic cell integrity using glutathione S transferase alpha (GSTA) and other liver enzymes. Results: The main significant finding was an apparently significant shorter length of hospital stay following BPVB as compared with GA in patients (P < 0.005). Conclusions: BPVB was superior to GA following abdominal ventral hernia repair in schistosomal liver fibrosis patients

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The application of opto-electronic in video-endoscopes aims to improve accuracy in diagnosis, through image processing and digital technology. Narrow band imaging (NBI), one of the most recent techniques, consists of using interference filters for the illumination of the target in narrowed red, green, and blue (R/G/B) bands of the spectrum. This results in different images at distinct levels in the mucosa and increases the contrast of the epithelial surface and of the subjacent vascular network. NBI is combined to magnifying endoscopy with an optical zoom. After being studied in prototypes the opto-electronic technique, now available in the most recent models of video-endoscopes that use the sequential R/G/B system of illumination, should be adapted in the near future for the instruments utilizing the non-sequential system of illumination. This new technique aims to characterize the surface of the distinct types of digestive epithelia, including intestinal metaplasia in the Barrett's esophagus. The technique also allows characterizing the disorganization of the vascular pattern in inflammatory disorders of the digestive mucosa and in superficial neoplastic lesions in the esophagus, stomach, and large bowel.

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It's still controversial whether certain macroscopic endoscopic features can be used to diagnose Helicobacter pylori (HP) related gastritis. The literature dealing with this subject is confusing, because of the lack of precise terminology, no large control trials, major discrepancies in interpretations of macroscopic changes and poor correlation of the macroscopic appearance and histological finding of gastritis. We conducted a prospective study of 208 dyspeptic patients, who underwent upper gastrointestinal endoscopies from February 1997 to June 1997. Only those patients who had either normal looking gastric mucosa or macroscopic gastritis were included in the study. Endoscopically normal looking mucosa was seen in 67 patients (65.6%), erythematous gastritis in 51 (74%), mosaic appearance in 18 (88%), erosive gastritis in 14 (85%), nodular gastritis in 17 (94%), atrophic gastritis in 12 (75%), and fundal rugae hypertrophies in 5 (80%). We suggest that the antral nodularity, raised erosions, mosaic appearance and mixed findings, are the reliable indicators of the underlying HP induced gastritis. However, these endoscopic findings are very specific, though not sensitive, for HP gastritis.

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One year before the close of the 19th century it was recognized that intestinal peristalsis was controlled by nerve plexuses in the wall of the gut independent of the central nervous system (CNS). This concept was developed further during the first quarter of the 20th century but was almost forgotten during the next 50 years until it was revived by the early 1970s. It is now recognized that the myenteric and submucous plexuses, referrred to as the enteric nervous system (ENS), contain as many neurons as in the spinal cord. In addition to autonomy from the CNS, the ENS employs not only noradrenaline and acetylcholine but also serotonin (5-HT), ATP, peptides and nitric oxide as neurotransmitters, and controls gut movements, exocrine and endocrine secretions and the microcirculation, thus qualifying for being considered the brain of the gut. Reflexes involving the ENS may be entirely intrinsic such as that controlling peristalsis, between parts of the gut through prevertebral ganglia e.g. the enterogastric reflex, or between the gut and the CNS as examplified by the vago-vagal reflexes. Absent, defective or dysfunctional enteric neurons may result in achalasia, infantile hypertrophic pyloric stenosis, paralytic ileus, intestinal pseudo-obstruction, Hirschsprung's disease or idiopathic chronic constipation. Further, the ENS may be involved in the pathogenesis of secretory diarrhoea and inflammatory bowel disease. More research on the gut brain will deepen our understanding of the physiology and pathophysiology of the gastrointestinal tract.

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Determination of the extent of progress of hepatic fibrosis is important in clinical practice, where it may reflect the severity of liver disease and predict response to treatment. Percutaneous liver biopsy is the gold standard for grading and staging of liver disease. However, liver biopsy is an invasive procedure with certain unavoidable risks and complications. Several methods have been studied in an attempt to reach a diagnosis of cirrhosis by noninvasive means. Fibroscan® has been designed to quantify liver fibrosis by means of elastography and found to have reasonably good sensitivity and specificity patterns, especially in patients with advanced fibrosis and can be used as an alternative to liver biopsy.

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A large proportion of the population all over the world consumes acetylsalicylic acid (ASA: aspirin) or other nonsteroidal, antiinflammatory drugs (NSAIDs). This is associated with a considerable morbidity and mortality. Elderly patients, patients with prior history of peptic ulcer disease (PUD) or its complications, those who require high doses of NSAIDs and those undergoing concomitant therapy with corticosteroids or anticoagulants, are at particularly high risk of developing gastroduodenal injuries and related adverse reactions. Gastroduodenal mucosal injuries induced by NSAIDs vary from subtle microscopic to gross macroscopic changes including ulcers. These injuries are induced by both topical and systemic actions of NSAIDs. Inhibition of gastroduodenal cyclooxygenase (COX) enzyme by NSAIDs is considered to be a major pathogenetic factor. Reactive oxygen species (ROS) appear also to play a significant role in the pathogenesis of mucosal injury. Withdrawal of NSAIDs is preferably the first therapeutic option; however, it is not feasible in the majority of patients. Therefore, several drugs including antisecretory drugs (ASDs-proton pump inhibitors and Histamine-2 receptor antagonists) and misoprostol, a prostaglandin analog are used for the prevention and treatment of NSAID-induced gastroduodenal injuries. Among ASDs, proton pump inhibitors (PPIs) are the most commonly used drugs. The antiulcerogenic effect of PPIs is similar to that of misoprostol and superior to standard doses of histamine-2 receptor antagonists (H2-RAs). The adverse effects of m,isoprostol such as diarrhea, abdominal pain, nausea, flatulence, headache, dyspepsia, vomiting, constipation, abortifacient and teratogenicity limit its general use. Aside from their antisecretory action, PPIs also possess an antioxidative effect. PPI maintenance is recommended in chronic NSAID treatment in those with an increased risk of complications and is more effective than Helicobacter pylori eradication. Low PPI dosage maintenance is as effective as a standard dosage regimen. The effect of H. pylori eradication remains controversial. It is advocated in naοve NSAID users, in chronic users with recent ulcer or ulcer complications and in those with an increased risk of ulcer and ulcer complications. In addition, some herbs have shown inhibition of gastric mucosal damage experimentally induced by necrotizing agents through their antisecretory and antioxidant properties.

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Chronic diarrhea is a complex symptom. The clinical approach and management should be based on pathophvsiologic considerations and stepwise laboratory investigations. In infants with severe malnutrition, nutritional support is a priority in the management of this condi­tion.

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In recent years, novel insights have been gained into the role of bacterial microflora in health and disease. Commensal flora manipulation by probiotic bacteria has been investigated in human and experimental inflammatory bowel disease. Various probiotic species have shown promise in the treatment of ulcerative colitis, Crohn's disease and pouchitis in small studies, although a clear clinical benefit remains to be established.

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The splenic artery is the most frequent site of visceral arterial aneurysms. Usually a splenic artery aneurysm occurs as a single event; rupture is frequent, sometimes occurring as the first symptom and is sometimes fatal. This article presents a case of ruptured multiple splenic artery aneurysms-the symptoms and signs, operative and perioperative management, as well as a literature review of this clinically important entity.

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This is a retrospective study of 59 patients endoscoped over a period of six years at a private clinic and were found to have esophageal candidiasis. The median age was 46.38 years. Thirty (51 %) patients had no precipitating factors. Only 18 (30%) patients had typical symptoms. The distal part of the esophagus was more often involved. The thrush was scattered in 57 (97%) patients. The endoscopic finding was confirmed by cytology in all patients included. Symptoms improved on oral nystatin treatment and simultaneous treatment of associated conditions in all 46 patients followed up. In conclusion, esophageal candidiasis appear to be not uncommon among dyspeptic population. It presents more frequently with atypical symptoms and responds well to oral nystatin treatment.

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Hepatitis C virus (HCV) infection, unrelated to blood transfusion is very common among hemodialysis patients with chronic renal failure. The positivity rate for anti-HCV varies from 18% to 91% among various countries. It is due not only to the past blood transfusions, but also to nosocomial transmission which is preventable. The main route of virus entry, is most likely, the two (arterial and venous) needle holes that are touched by the fingers of the physi­cian and the nurse repeatedly. The recommended preventive measures include: the use of a sterile glove, finger sterilization with a disinfectant solution, immediately before touching the needle/needle hole. and repeated education of the staff. Whether the anti-HCV positive patients should be separated from the negative, largely depends on the prevalence of HCV infection within the dialysis unit.

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Several parasites infest liver or biliary tree, either during their maturation stages or as adult worms. Bile iry tree parasites may cause pancreatitis, cholecystitis, biliary tree obstruction, recurrent cholangitis, biliary tree strictures and some may lead to cholangiocarcinoma. This review discusses the hepatobiliary parasites, and shows our experience in diagnosis and management of these parasites. Ultrasonography of the liver is diagnostic in schistosomiasis, hydatid cysts, amebic liver abscess, ascariasis and other biliary tree parasites showing bile duct dilatation. Percutaneous aspiration under ultrasonography guidance of hydatid liver cysts or amebic abscess are effective measures in management. Endoscopic retrograde cholangiopancreatography (ERCP) is safe and effective in diagnosis and management of biliary tree parasites.

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Hepatic encephalopathy (HE) is a disturbance of the central nervous system (CNS) function secondary to porto-systemic shunting. It usually occurs in the setting of advanced liver cirrhosis or acute fulminant hepatic failure. An extensive Medline search was undertaken and all relevant papers found were critically examined. Special emphasis was paid to clinical trials and meta-analyses. All guidelines and conference proceedings related to hepatic encephalopathy were also examined. HE presents with a spectrum of neuropsychiatric manifestations that may be quite subtle (minimal HE) or overt, ranging from disturbance of the sleep pattern to deep hepatic coma. Most patients with HE may be diagnosed on clinical grounds only after excluding other causes of neurological disease, but a wide variety of neuropsychological, neurophysiological, and neuroradiological tests may be utilized. The first step in the management of patients with HE should be supportive care. Following that, a significant effort must be exerted to find and correct possible exacerbating factors which may include: renal impairment, infection, constipation, drugs, gastrointestinal bleeding and other factors. Medications used to treat patients with encephalopathy aim to reduce toxin production, increase toxin elimination, and protect the brain from the harmful effects of these toxins. A critical analysis of the evidence concerning most of the available management modalities is presented. Ultimately, all patients with HE must be considered for liver transplantation. It is concluded that early recognition, positive diagnosis, and a multi-target management plan constitutes appropriate management of patients with HE.

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